Comments on: Is the impending physician shortage worse than we thought?

By: Jeff Brandt

Jeff Brandt — Thu, 05 Nov 2009 01:40:12 +0000

Doc Stone, I agree that privacy and security should be a top priority. I worked in Internet banking security with CyberCash and ICVerify now owned by Verisign for several years. Security is not that difficult, it just takes money, C-level buy in, and the correct engineering personnel to make it happen. One of the major problem is healthcare is relatively new to enterprise IT. Many doctor offices and hospital still have rows of PC running each application. These are desktop apps not enterprise software with very little security. Many systems today including EMR and PHR are basically desktop application written by people that have no clue about writing secure software not to mention enterprise software.

The next problem is perception. Most end user and administrators only give lip service to security. Most people will give their credit card number and ID to almost anyone without question or toss important document in the trash without shredding. Everyone says that they want security but will they pay for it or provide the extra steps to support it? No.

CSI, my company has one of the only secure encrypted medical apps on iTune but most user do not care and do not want to pay anything extra to keep their data secure.

Many security problem today can be solved with low tech solutions such as locked doors, and correctly formed security policies. The other solution is Medical Record banking where the patient pays to store their records in a safe and secure location. But this is a hard sell in the age where everyone want everything to be free.

Unfortunately, we will have experience breaches before security is really taken seriously.

Jeff Brandt
http://www.comsi.com

By: Doc Stone

Doc Stone — Thu, 05 Nov 2009 00:54:19 +0000

No discussion of EMR should go without mention of the problem of privacy and security. If it were one “easily solved” then hacking wouldn’t be a massive industry. EMR medical records outsources the physicians ethical obligation to others outside of his control.

By: anonymous

anonymous — Mon, 02 Nov 2009 12:33:51 +0000

to xerxes-can you type faster than you can talk?
there are lots of physicians who can type. it is still slower than dictation. electronic charting also takes a lot longer because of the requirements for charting have increased and more people latch on to the document as a place where they can have the requirements for their department inserted into. log in times, loading times for documents, computer hangups etc add up to big delays. i will admit there are benefits to having multiple people being able to access the chart simultaneously, but if physician time is the most precious resource, then emr is a net loser.

By: Paul MD

Paul MD — Mon, 02 Nov 2009 12:26:42 +0000

I didn’t start the fire. I don’t live in a vacuum either. You are correct that my surgical nurse communicated with the PMD’s nurse who asked the PMD who said they had no time. It is also more expeditious for me to use communication extenders but I also find that pressuring a physician to do anything that may interpret as “how to run their practice” breeds anger, contempt and can and has negatively affected referrals. It is a sad reality.

We don’t ask for the fictitious “surgical clearance” that you mention. It is the policy of the hospital that a letter dated within 30 days, preferably from the PMD that satisfies that the patient is maximally medically managed for surgery be included.

The referral was “emergent” , his surgery was “urgent” and did leave time for the above required/highly suggested input from the PMD or PMD office.

I agree the PMDs are getting screwed. No argument there. I know they are poorly represented at the RUC committee which is specialty weighted.

I am honestly pleased that someone as thoughtful as you took the bait of my letter to digress from the initial topic and shed light from a different perspective…a hybrid perspective as an oncologist. I know I cling to the ROAD rules when it serves my point, but I also know, without trying to sound haughty, the real value of my services. I and we, including PMDs, have nothing to apologize for. Thanks for you input.

By: Xerxes1729

Xerxes1729 — Mon, 02 Nov 2009 01:19:06 +0000

EHR software will improve over time, and as more people who grew up wasting time on computers become doctors, physicians as a group will become more efficient users of technology. My dad complains that his hospital is making him chart electronically, which takes him twice as long as charting by hand. I complain when I have to write notes by hand because I can type so much faster than I can write.

By: TrenchDoc

TrenchDoc — Sun, 01 Nov 2009 18:45:44 +0000

You are correct it is not all beer and pizza and if it was we could not agree on what type of beer and pizza we would be ordering. In our determination to be idependent as physicians we have lost our focus on the patient. Each physician camp can give examples of the others abusive behavior. It is time to stop playing that old game and hookup with other docs whose first thoughts in the morning are about their patients.

By: elmo7

elmo7 — Sun, 01 Nov 2009 17:48:12 +0000

I am sorry I have to respond to Paul.
Editorial comment: I am a medical subspecialist not a PCP.
Paul, you have fallen into the “ROAD” version of how the medical life is. It is not that way in the real world. The fact is many subspecialist’s use extenders. It has been going on for years. Are you that clueless as to life outside your office? Though you can haughtily talk about how PCP’s/hospitalists “made there choice and seem to have chosen poorly”. Reality, for the majority of americans it is much more important as a sociiety to have an adequate and competant number primary docs than optholomologists or (in case my) oncologists. Very simply you and I are paid what we are paid based on RVU’s set up by one committee. Personally I don’t feel that I am overcompensated. I do think that PCP’s are getting screwed, Maybe that is the difference. I see and interact with PCP’s everyday in the hospital. I suggest you do the same. Your outlook might change
Lastly, it is good that you where able to get your example patient in the next day. But why pat yourself on the back and what is your point? I do it all the time. It was an emergency right? Did you personally talk to the PCP and relay your concerns and need for prompt surgery? Or where you “to busy” and let your office work on it? You also fall into the fallacy of “clearance”. PCP’s don’t “clear”, They risk assess. I have got a secret for you. 10 minutes on uptodate with the Eagle criteria and an EKG and you can “clear” (your word) the patient yourself or not. But that would involve using a little of your med school and internship experience. What do you think anesthesia did?
Paul:
The fact is primary medicine is crumbling. I manage patients primary issues all the time. Not because I want to, but because I have no choice, I am glad you can just say “go see your PCP” on issue outside the eyes, whether they have one or not. I don’t have that luxury. But I guarantee you will be getting more and more of those questions in the present system. THis divide and conquer atmosphere between docs has to end.

By: Brad

Brad — Sun, 01 Nov 2009 17:18:28 +0000

In my state (Michigan), the number of medical students has increased dramatically in the past few years. Other options would be to increase the capabilities and numbers of nurse practitioners and physician assistants. The time in medical school could be decreased. State licensing of physicians could be changed to medical care practitioners.

By: Paul MD

Paul MD — Sun, 01 Nov 2009 16:37:15 +0000

Clearly there are many different cultures in what remains of the house of medicine. Primary care has contributed to the slitting of their own throats with the use of extenders to the point that the “MD” sits in front of a computer screen somewhere in the office like the Wizard of Oz. Hospitalists do their in-house patient care duties while the PAs and ARNPs work the trenches at the offices. The “doctor” polishes up the notes so that (if hospital employed) they can meet their target projections for billing. I would hate doing what they do and I never would have chosen it as a career path. They had a choice, just as I did, and many of them seem to have chosen poorly.

The few times I have had to see my doctor (yes, I have an expensive, high deductible insurance) I end up seeing an extender. When someone is sent to my office, they see ME or one of my other subspecialist BOARD CERTIFIED PHYSICIAN partners….regardless of their insurance or lack there of.

I would advise my fellow physicians to think long and hard about picking fights with specialists and subspecialists. Your hospital employers will tell you, if they are honest with you, that you are a loss leader to gain access to testing and lucrative surgical cases. I understand your frustration, but you should turn your anger toward the true source. The beloved Federal Government that you are crying to now. If you truly believe that they have any interest of yours in mind, you have collectively made another bad decision.

I deal with the hostility and the passive aggressive nature of some of the local primary care providers on a daily basis and it is petty.

This happens routinely. I accepted an emergent referral of a medically complex patient two weeks ago from a comprehensive ophthalmologist in another part of my state. We moved 18 office patients and then booked the patient for the following day (for the privilege of a financial loss on a retinal detachment surgery, as we always do). I told the patient that we will need an H&P from his primary and called his office at 1300hrs on a Tuesday. The patient smiled and said that shouldn’t be a problem as Dr.XXXXXXX has been his doctor for thirteen years. Dr. XXXXXXX’s office told us that they didn’t have time to see him and that other options would have to be considered. The patient looked deflated. Thankfully, the very strong anesthesia department took charge and cleared the patient for surgery. He is doing well. His relationship with his “doctor” is bruised.

Divide and conquer seems to be working well. You should try walking in our shoes sometime. It’s not all beer and pizza.

By: jsmith

jsmith — Sun, 01 Nov 2009 16:17:40 +0000

Jeff, EHRs are wonderful unless you actually happen to be a doctor or nurse who uses one. The increased productivity/ care improvement thing is a myth, now and in the future. Why? The American people have been sold a bill of goods on EHRs. The thought is that we don’t know what to do and EHRs can remind us, and that we don’t communicate and EHRs will help us. The diagnosis is wrong. We know what to do, and we know how to communicate. Why don’t we? Lack of time. And of course EHRs worsen our lack of time. It costs me an extra hour per day to fool with the computer. Don’t buy the increased productivity foolishnessThat is commercial puffery created by vendors, pushed by pundits- for -pay, and believed by gullible or mendacious politicians and the unknowing public.
See Bob Wachter’s article on EHRs on this website. EHRs are a misbegotten technology. Sorry.
That said, if society wants me to pay me my usual salary to fool with the EHR, fine. But that means I see fewer sick people and my waiting list gets longer. Not a valuable use of my time IMHO.